Welcome to Episode 19 of Contain This, brought to you by the Indo-Pacific Centre for Health Security, hosted by Head of Centre Robin Davies.
Today on the show Robin talks to Dr David Nabarro, a British medical doctor who has been at the forefront of international organisations as a special adviser to the United Nations and the World Health Organization.
Since 2009, he has been the Special Representative of the United Nations Secretary General for Food Security and Nutrition. He oversaw the global effort to contain the 2014-15 Outbreak of Ebola as Special Envoy of the United Nations Secretary-General.
In 2018, he was appointed Professor at the Institute of Global Health Innovation at Imperial College London. And most recently he was named as one of six Special Envoys from the Director-General of the World Health Organization to help respond to the COVID-19 Pandemic.
Robin is joined by panellists from around the region, who you'll hear ask questions during the episode.
For more information about the Indo-Pacific Centre for Health Security, visit our website https://indopacifichealthsecurity.dfat.gov.au.
Connect with us on Twitter via @CentreHealthSec and @AusAmbRHS.
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Contain This Team
Please note: We provide transcripts for information purposes only. Anyone accessing our transcripts undertake responsibility for assessing the relevance and accuracy of the content. Before using the material contained in a transcript, the permission of the relevant presenter should be obtained.
The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.
Dr David Nabarro, Special Envoy to the World Health Organization Director-General on COVID-19
Robin Davies, Head of the Indo-Pacific Centre for Health Security and the Department of Foreign Affairs and Trade's Vaccine Taskforce
Sunia Soakai, Public Health Unit, The Pacific Community
Sandii Lwin, Myanmar Health & Development Consortium
Helen Evans AO, Indo-Pacific Centre for Health Security Technical Reference Group.
Dr David Nabarro 00:00
I've been making the point for some time that if you want to take local initiative and local action to scale, it's not simply a case of massively increasing inputs in terms of cash or in terms of goods. And expecting that with the extra inputs, you can get much greater output in terms of greater resilience. Resilience, particularly when you're working on a local level involves small groups of people into interacting together, being nurtured, using the word I used before, at the local level.
Mr Robin Davies 00:42
Welcome to Contain This. I'm Robin Davies, the head of the Indo Pacific Centre for Health Security. Today I'm talking to Dr David Nabarro, a British medical doctor who's been at the forefront of international organizations as a special advisor to the United Nations. Since 2009, has been the special representative of the United Nations Secretary General for Food Security and Nutrition. He oversaw the global effort to contain the 2014-15 outbreak of Ebola as special envoy to the United Nations Secretary General. In 2018, he was appointed professor at the Institute of Global Health innovation at Imperial College London. Most recently, he was named as one of six special envoys, of the Director General of the World Health Organization to help respond to the COVID-19 pandemic. David, welcome to Contain This. So David, I just want to refer initially to a series of narratives that you have published, in many cases together with colleagues, on COVID-19. There's quite a series of these. And can I just ask a pretty basic question, why do you call them narratives rather than articles, blog posts, whatever? There's something about that term that evokes storytelling, so why do you use that term?
Dr David Nabarro 02:13
Okay, why do I use the word narrative? Most of my life now is spent dealing with really complex challenges. And increasingly, I see them as systems challenges. And I'm using the term living systems to describe systems that are made up of people. And when you're dealing with people-based systems, it's really important to recognize that one has to work with the people in the systems if they're going to function more effectively. And there are three central elements to the effort to shift systems that I’ve become increasingly convinced of. The first is the need to have a clear story to describe where everybody is headed, that people can adhere to. And that's try quite tricky, because the beginning, when you're doing systems work, everybody has a different perspective on the change. And I tried to use narrative often co-created by groups, as a way of bringing people together to find the pathway along which they wish to move. The second word that is meaning a lot to me, is networks, because you can't do systems change without people. And you know, in my experience, people within hierarchies or who are stuck within very procedural settings, find it very hard to do the flexible movement and adaptation that's necessary for systems change. And the third word that I use is nurture. That within efforts to change systems, one has to nurture connections, unusual connections between different actors. Right at the centre of this work on COVID has been, in my view, the need to be developing narratives that make sense in different places. The systems change issues required for COVID, or linked to COVID are inherently complex. And that's why I use the word narrative to describe the pieces that we produce. I wish we could produce them more regularly.
Mr Robin Davies 04:15
If I can ask just one follow-up there. In the early stages of the COVID response, I think there was a tendency for particularly donor agencies to focus on supporting technical containment solutions and thinking that community level prevention and control was probably something that would get supported later if the initial containment measures failed. You can question that logic but I'm wondering... you talk about the greater consciousness now for the need for local solutions, community based action. Could that be in part because there is a perception that the problem is running out of control? Is that part of the incentive for people to think about community level preparedness?
Dr David Nabarro 05:06
I've got two answers to that. I'm going to start perhaps being a little bit facetious. When we're working with living systems, and we're putting people at the centre of our action and we're putting those who work inside the systems very much in positions where we treat them with full respect and try to empower them and ensure they have agency to act. There are people who get it, and there are people who don't get it. And actually, in early COVID, finding the people who get the importance of people-centered working and living systems working has been very difficult. So much of the thinking around COVID has been based on there being sort of technocratic solutions - be it apps to put on cell phones or specific techniques for trying to reduce the morbidity associated with the disease and so on. And the recognition that actually getting ahead of this virus is fundamentally about enabling people to organize themselves to be strong has just not been a feature, at least in advanced nations. Of course, working with colleagues in Nigeria, or in Senegal, in Kenya, in South Africa, it's been a completely different situation. They have approached COVID, as they might have approached any other infectious disease issue. And they have been much, much more effective, because they have used local organization capacity to get on top of the threats posed by the virus. Now, this is shifting a bit, it's shifting slowly in in European countries, and there's a different consciousness now. But it's a little bit late, because quite a lot of the necessary environment, the nurturing to get this sort of systems working going in Europe depends hugely on political situations being quite tolerant and supportive. But there is a lot of political intolerance in different parts of Europe right now. You get standoffs between different political groups, as for example, as happened in the UK, between the mayor of Greater Manchester and the Prime Minister's team in London. And it's such a pity because actually, there's a lot of good sense to what the Manchester people are trying to do. And it's nothing to do with case numbers. It’s to do with actually building the capacity in these quite major urban settlements like Rochdale and Oldham and so on in the north of Manchester, because there is a lot of COVID there. And, okay, so the numbers may be fluctuating. But we know there's COVID there. And we know that it's in communities that are that are not the most prosperous, that are not in the mainstream of a lot of civic life. And that really special efforts do need to be made to engage those communities, and have them fully participating in efforts to reduce the risk of the virus gets transmitted. And also, to maximize the opportunities for interrupting transmission. It's back to the basics of infection control, that we all know about, Robin, and you in the Centre, you work on these kinds of things. But trying to reintroduce what you need for that way of working in terms of human organisation is really tough at the moment in the very acrimonious political environment in the UK. It doesn't mean we won't do it. We've got to go on doing it.
Mr Robin Davies 09:10
Thanks, David. I'd now like to invite Sunia Soakai to ask the next question.
Mr Sunia Soakai 09:17
Malo e lelei and Pacific greetings everyone. My name is Sunia. I'm the Deputy Director for the Public Health Division in The Pacific Community working out of Suva [Fiji]. Thank you for inviting me to be part of this session. David, the theme of localization runs prominently throughout your narratives. We talk about the need to tune into local realities, including building community resilience. Can you elaborate on that, please?
Dr David Nabarro 09:44
Thank you. Last year, I was working with the UN Secretary General on a climate summit and it was interesting to see how this was really demonstrating the shift from climate action being almost entirely preoccupied with mitigation to a real recognition that there are tens and indeed hundreds of billions of people in our world, who are now having to cope with changing climate and they're having to build resilience into their livelihood design and resilience into their local communities. Because otherwise their likelihood of really having major crises was constantly increasing because of changing weather. And all the work that we did on that, from the team that I was involved in, in the UN, plus those we worked with, outside the UN, was based on contact with people in countries. In fact, you're in Suva. And one of the countries that was right in the centre of our working was Fiji - we had a lot to do with the Attorney General and even with the Prime Minister on thinking through what resilience in Fiji does involve. It was very much focusing on local action, local actors having the resources they need, building on their indigenous knowledge, indigenous in its generic sense, and also drawing on their capacities to actually work in the local environment because they knew what they were dealing with. They knew some of the issues they had to prepare for. I mean, it came over really well. I think the recognition that local-level resilience is an absolutely vital property for all societies that are dealing with climate change was recognised. It is so hard to incorporate that thinking into the sort of broad brushstroke planning and action that comes out of international meetings because everybody is obsessed with this concept of “going to scale”. And I've been making the point for some time that if you want to take local initiative and local action to scale, it's not simply a case of massively increasing inputs in terms of cash or in terms of goods. And expecting that with the extra inputs, you can get much greater output in terms of greater resilience. Resilience, particularly when you're working on it. and local level involves small groups of people into interacting together, being nurtured, using the word I used before, at the local level. And it's very size specific, you have to keep relatively small if these interactions for local empowerment are going to work. And so scaling up local level, resilience is a much more, I think, judicious act than just simply putting in more input variables. And it is about working to ensure that there is what I call “a honeycomb growth of local solidarity actions”, rather than trying to do it through just greatly increased levels of inputs. And I’m again not sure that this is very well understood. So I'd like to continue to work with anybody who is involved in building local resilience and tried to understand what are the different approaches that work best.
Mr Robin Davies 13:46
And now I'd like to invite Helen Evans to pose a question.
Ms Helen Evans 13:51
Thanks, Robin. I'm Helen Evans, and I'm a member of the Technical Reference Group for the Health Security Centre. And I have an honorary appointment of the Nossal Centre for Global Health. But I've also previously worked internationally at the Global Fund and GAVI. And it's nice to be in touch again, David. I wanted to ask you about leadership. I mean, you've talked a lot about the importance of leadership in this pandemic, and that good leaders should ensure that no one's left behind, or indeed left out, which is slightly different. And I'm wondering if you could two questions. Actually, I'm wondering if you could give us - you've already referred to some - give us some examples of good political leadership that is inclusive, and also whether you've seen leaders who've actually learned and evolved, particularly in relation to inclusiveness over this pandemic. And the second thing I want to ask you, which is, I was intrigued by your comments about the fact that this pandemic has become very politicized, particularly in high income countries. And I wonder whether you think there's a relationship between the fact that in high income countries we haven't, they haven't had to cope with pandemics and epidemics in a way that many people in lower income countries have as a very real lived experience. Thanks.
Dr David Nabarro 15:13
So, Helen, it's lovely to be connected again. Let's start from your second point. And it's building on something I've said before, that I quite like to set a bit more strongly. In high income countries, there has been less need to build into public health systems, the capacity to deal with infectious pathogens of the kind that we're dealing with right now. And so if we look at public health in high income countries, it's very, very different from the elements of public health in those places where there's a lot of infectious disease and you have to be constantly on guard for new pathogens emerging. One could argue, therefore, that this is, in a way, because systems have forgotten how to deal with things. But there's possibly another side to it as well, that perhaps there's been a deliberate effort in some high income countries to reduce the functioning potential of these local systems, perhaps it's proved to be easier to govern from the centre, and to perhaps give less autonomy and agency to local actors for reasons that I may not be able to go into right now. But whatever it is, there is a suggestion to me that the governance capacity at local level in high income nations is an awful lot less than it needs to be to support the kind of local solidarity responses for this virus. And that does matter, because what high income countries do is sometimes seen as an exemplar for others in particularly, when one thinks of development as a trickle-down phenomenon. And so, I mean I do sometimes wonder what those in lower income countries are now thinking as they see some of the contortions that are occurring in high income countries. In coming to terms with the local solidarity and organisation that's needed to do with this virus. I'm sure that political scientists will be able to explain to us what's happening. Just at the moment, it feels like a lot has been forgotten, it's having to be learned very fast, that learnings are not happening in any kind of smooth way. There's a lot of current happiness with different aspects of the system. If we go to Britain, France, Spain, it's manifesting in some quite difficult ways. And as I said before, it's not an environment, which leads to the easy kind of shift towards localised action. And so this is a big challenge, a big Leadership Challenge back to your first question. And so to get the kind of leadership we need to support local solidarity responses. It's interesting, and I've been thinking about this such a lot. It's also been in some of our narratives, you may have seen. The first thing is about values. No leadership activity has any meaning to me, at least, unless the values of the leaders are really very evident, and are actually quite well displayed. I love the focus in in much corporate leadership now on purpose being at the centre of what CEO and management team have got to be working for. And more and more, I like to see the purpose, the extent to which it's actually spread throughout the company so that the values which then determine the purpose of leadership, for me are vital. second is that you can't do systems work without recognising that no single perspective on what's happening in a particular situation should be treated as right in an absolute sense. It's necessary to recognise that each different person will bring their own perspective when looking at the performance of a system and one needs to be able in systems change work to actually have space to work with all different perspectives simultaneously, even if you can't directly work with them, at least to recognize that they exist. And I think that's hugely important than the leadership that's necessary for local solidarity. I've got four other things that that I find to be important that second is being able to see big system and more detailed little systems issues at the same time, so that you don't just deal with the small issues and ignore the big systems challenges, you don't just focus on the big challenges, and ignore the detail. So I find good systems leaders are able to very quickly shift from having a big picture view and having a very local view and back again, and also to recognize that these won't necessarily be consistent all the time. Third thing is being able to feel the rhythm and the pace of an environment within which the system is operating. And to adapt systems change efforts to take account of that rhythm and pace. Rather than trying to impose your own rhythm and pace. We've all seen that, when we get a bit fed up, sometimes when we say I'm going to really come in, and I'm going to push this situation. And so we go and we possibly are a bit blunt, or we're a bit disrespectful, impatient, and things can go very wrong very quickly. So I’m a big fusspot on that. Fourthly, to recognize that the way systems work has a very local relevance, you must see this such a lot where you're working, that you're dealing with very different contexts. And so you have to all the time be adapting, adapting, adapting, and not following some kind of cookie cutter, rule-based system, but instead, really feeling what's happening locally, sensing it, and reacting. And lastly, meeting people where they really are, rather than where you want them to be. It's a bit similar to the rhythm and pace, but it's about whether or not when you're working with people, you can really make the effort to tune in to how their heads are seeing issues rather than how you're seeing the issues. And it's quite interesting, therefore, that some of the very best systems leaders that I've seen emerging at the local level in France, where I'm living the moment or in UK, and in developing nations, it's interesting that the superstars and not necessarily the ones that you identify and say yes, here is a great person, but that that's partly also healing because I probably don't have quite enough in my in my list, like everybody, I am enormously impressed by some of the leadership that I'm seeing in both New Zealand and Australia, in Vietnam, in Singapore, in Cambodia, in Taiwan, in China itself. In South Korea, it's really amazing systems leadership by lots of different actors, the mayors and their supporters. And so I think probably if I wanted a big list of examples, I'd come to your part of the world. But I'd also be looking a lot in Africa at the moment. And I've got some few names from there as well. Thank you.
Mr Robin Davies 23:15
So David, just building on Helen’s question a moment ago. You know, we're all very focused on league tables of COVID cases and fatalities, and so on. But without discounting the impact of COVID on developing countries, for many of them, it is one more burden and often, it's quite possible that the biggest negative effects will be through its indirect impacts on the on the health system, on the aggravating effect it has on a whole series of underlying problems. So I'm interested in your perspective on that, who do you think ultimately, I guess the simple way to ask this is who do you think ultimately will all suffer the most, when you take into account all the indirect impacts of COVID on already fragile health systems?
Dr David Nabarro 24:12
When Robin, when the run of show came through and I saw this question, I thought this is the tough one. And it's tough because I still think we're at the early stages of our relationship with this new virus, and there are constant surprises and they're not always nice. And so let's start with the virus itself. Yeah, it causes fatality. And that in older people and people with pre-existing conditions but I've got so concerned about what in Europe is called Long Tail COVID. This is people who have continuing symptoms, perhaps for three months or even longer after their initial infection. And the studies being done, suggest that at the beginning, like a month after the COVID started as many as one in 10, have the symptoms and then if you go on six months, then it's perhaps one in 20, or one in 30. But this is an awful lot of people. And if this long and unpleasant debility is widespread, then the world is going to be facing several years with large communities of people who are feeling variously short of breath on exertion, or mentally fatigued or with varying other symptoms that impair their ability to function physically and mentally. So I'm still not sure what the long term effects of the virus on the individual's effects are going to be. And I am keeping an open mind as to how Long Tail COVID will play out in different settings. Of course, the desire of governments to shift to using stringent restrictions on movement as a primary containment strategy at the beginning, was unfortunate, because it did lead at certain points to something in the region of half the world's population in the early months of 2020, being in various stages of what's commonly called lockdown. And we haven't got the full information in but it's suggesting to me that, for some months, there was perhaps nearly a doubling of the number of very poor people in our world. This was because for so many tens of millions and perhaps hundreds of millions of people, who were on daily wages, that there was a period when income stopped. And the social protection schemes that would it be necessary to keep income going, it just can't be switched on just like that overnight, when you've got very massive increases in income poverty like took place. So the second big challenge caused by COVID has been the fact that countries weren't ready, they had to impose lockdowns and lock downs have had really massive impact. That's one of the reasons why we've been a bit explicit recently, in discouraging the use of lockdown as the primary containment measure just because of its consequences. So I think there's been a lot of transient poverty, transient poverty will manifest itself in long-term malnutrition among children, not quite sure how serious it's going to be different people have given different estimates and so hard to get to get actual numbers. But I suspect we're going to see a cohort of children who've had physical stunting during 2020. And who will have consequences thereof, unless we can be very skillful. then there's going to be the impact of the fact that health services generally around the world have had a period of perhaps again, about three months in which they've just been not performing. Women haven't been able to get reproductive health care in many settings. People who've got chronic conditions haven't been able to get treatment for that. And so there are significant as well as poverty and nutritional impacts. There's also health service impacts and then lastly, COVID has shown us and continues to show us just the incredible inequities that exist in societies. And so we are also going to have to come to terms with the fact that there's a lot of revealed inequity in many sectors that we didn't realize, and probably there will be a necessity for governments to be thinking very hard about how to deal with it and depends of course on the governments but will there now pay attention to the living conditions, for example, in countries that have foreign workers coming in and being putting them in overcrowded dormitories, not fussing too much about the living conditions. But now it's clear that these situations, as we've seen in Singapore are associated with COVID. Will that mean that there'll be changes to how people live? Will there be changes to how meat and fish processing and vegetable processing operations work? Because they clearly have been associated with a lot of COVID for a mix of reasons. Will they change? So there's another issue inside your question, which is whether or not the revealed inequities in society, which show us just how much suffering there is, and that perhaps we've been able to ignore, whether those are now going to be given attention because of the way in which COVID has shown us just how much core suffering and misery there is for poor people in so many sectors that we've taken for granted. And I hear I'm particularly referring to agriculture and food.
Mr Robin Davies 30:50
Thanks David and if I can sort of tax your predictive powers a little more, if we assume that non pharmaceutical interventions are going to continue to be very important, perhaps even after there is a first generation vaccine. I wonder what a COVID-adapted world might look like in your mind, particularly for developing countries, especially in densely populated developing countries with fragile health systems?
Dr David Nabarro 31:23
Another super tough question, Robin, I like your use of COVID-adapted, you know that we've been using COVID ready We recently, in one of our open events, started looking at the terminology. But whether it's COVID ready, COVID-adapted, COVID secure, COVID prepared, it is going to require changes in our collective behavior. And it's going to apply to all people in our world. It's not going to be possible just to say, let this virus go and do its mischief, we're going to need all of us to find our way to live with the constant threat of this virus. And we'll work out what that means, in practice. I think physical distancing in various forms is going to remain important. I think we'll get better at understanding the value of face protection. It's, it's one thing to wear a mask badly, it's another thing to wear good well-fitting face protection and do it well. I think we'll get better at that. I think our hygiene practices will continue to improve. I'm so pleased to see, for example, a flu incidence in the southern hemisphere in the winter appears to have been lower. We had that before, by the way in 2009-10 with a flu pandemic. That nonpharmaceutical surgical interventions can be incredibly good, not just for this virus, but also for other viruses. For older people, I think there will be a bit of ghettoization of older communities coming up. Now, I think that this adaptation will happen everywhere. I know that at the moment, we're hopeful that perhaps the situation isn't so bad in some African settings. But I don't think that's a stable situation. I think the virus has the capacity to cause mayhem for some years to come. So I actually think that those five activities are going to become much more commonplace in human existence. But fairly quickly, we'll get used to it and a bit like the shift to safe sex when HIV was discovered to be sexually transmitted. It's something that most people got used to quite quickly, it took a year or two. I think that sense-making on COVID will be a bit quicker. I think in six months time, nine months time, we will see pretty widespread practice of the non-pharmaceutical interventions, in most settings. Where it will be a problem is in densely populated communities. I was looking at some information from Honiara, saying that that's going to be tough. I'm thinking about how you do all this in densely populated places where there's a risk of violence in the domestic setting, I think there's gonna have to be a lot of thought about what practicing the non-pharmaceutical interventions will mean for people's lives and looking out for people, individuals or groups who are perhaps not going to come out with it well. I've got a particular thing in my head at the moment about gender-based violence, which I think I'm nervous about, associated with isolation.
Mr Robin Davies 34:38
Now I'd like to go to Sandii Lwin from Myanmar. Sandii, I'll pass over to you to ask your question directly, if you can just introduce yourself first.
Ms Sandii Lwin 34:49
Thank you. So I wanted to ask a question on issues that countries are facing with COVID patients. So as you know, we're seeing increasing number of cases from the second wave of COVID-19 in many countries in our region, including in Myanmar. What can we do when you have situations where the health system is at capacity to isolate positive but less serious cases, and also where people are unable to self-isolate due to their living conditions, such as in peri-urban areas or informal settlements? What measures do you think we can take?
Dr David Nabarro 35:32
Thank you, Sandy, nice to be connected. I've been focusing my own attention on Nepal, you know, that's a country where I work for five years. And I've got people writing to me quite regularly and explaining the massive challenges that they are faced and actually I don't have answers. I don't know what the situation is in Myanmar but in other parts of Asia, I'm hearing you’ve problems of testing, we don't know where the virus is, finding it very hard to work out which are the groups that are at high risk for transmission. If one did have better virus testing, one could say, well, these are particular parts of the country or particular parts of neighborhoods where there's a lot of transmission and it would be possible to do very focused efforts to try to reduce transmission. Then the second challenge, what about access to care? it's in two parts, one is that health workers are exhausted, sometimes threatened, and often worried for their own health. And then secondly, there just aren't the resources to treat patients. I mean there aren't intensive care beds to speak of in many settings. And so the actual clinical care stuff gets very difficult. And then the third part is that when governments when they get stuck, tend to want to introduce movement restrictions, but that then compounds things by increasing poverty. So I don't have a simple solution. I am quite keen to actually stop encouraging everyone to think that the only way to treat people with COVID is by having intensive care beds. We look at what's happening in Europe, there is much more care being provided outside intensive care, keeping people off ventilators, doing treatment with things like dexamethasone early on to try to prevent autoimmune problems actually provoking severe illness and death. So I would just say, do everything possible to do early interventions. If you have got oxygen, it's terribly useful. Everybody's saying in WHO that they think that more than anything else, ensuring that there is oxygen for people who have got a low PO2 because they've got stiff lungs, that's terribly helpful early on and I'm still hopeful.
Ms Sandii Lwin 38:15
Thank you, David.
Dr David Nabarro 38:16
What a stunning group of people. It's been lovely. What a lift for the day. Thank you.